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AA <br /> SEWIN AVSZl E 0 'S 'AO N-(awII pania0a� <br /> CITY OF MANTECA_WQCF <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> 1. PRODUCER OF I..IOV WASTE pH <br /> NAME1'&'S C Zc PRO G f L7 <br /> PICS-UP ADDRESS <br /> Number Street City State Zip <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from(circle one eptic T Portable Toilet <br /> PICK-UP DATE TrVIE QUANTITY Z ais <br /> 1 <br /> I certify that this waste was delivered to the hauler named below for legal disposal at the site indicated. i <br /> Printed Name of Owner,Occppant or Agent Signa of Owner, cc pant or eat <br /> 2. IaAULEQ <br /> NANV- Roto Rooter• <br /> BUSINESS ADDRESS Q7'1 e6_ Cr� <br /> Number Street City State Zip <br /> I certify that the described waste was hauled by me to the disposal facility named below- <br /> Receiving Station permit No. J/ Vehicle Licevse No.27�X <br /> Printed Name of Hauler Signature of Haul& <br /> 3. REGFJVJNG STATION <br /> NAME AND ADDRESS: City of Manteca WQCF 2450 West Yosemite Ave. Manteca,CA 95337 <br /> I certify that the hauler above delivered the described liquid waste to this disposal facility,and that it was I <br /> accepted/rejected(circle one)material under the terms of-the Receiving Station Permit. <br /> - I <br /> Signa a Vaste)Pacility Operator <br /> i� <br /> DATE JL-_L4__I_ TIMEIN__L 4 TIME OUT ' ( NET QU'ANTI" Y21'3 2 gals <br /> Rev.07J00`office WmktanVforms <br /> V0/60 39Vd a3100a 0101 9Z6999V60Z 9Z:80 6TOZ/90/TT <br />